30 August 2009

The answer is in the last sentence on this film clip. [Sorry the clip has now vanished and Dr Grumble can no longer remember what the last sentence was!]

Perhaps you cannot believe that, as the Americans are looking for a different way to fund their healthcare, we in Britain are moving towards a system more like theirs. But we are. Hospitals now put bills in. One part of the government system is paying another part of the government system. It is very inefficient. It is inefficient because you have to spend a lot of time commissioning services and invoicing. At one time we had absolutely no idea how much things in the NHS cost. We often still don't.

When an outside manager was brought in to look at the NHS he must have been gob smacked. The NHS had no real continuous evaluation of its performance against normal business criteria. Little was known about:

levels of service

quality of product

operating within budgets

cost improvement

productivity

motivating and rewarding staff

research and development

Precise objectives for management were rarely set.

There was little measurement of health outcomes.

There was little evaluation of clinical practice

There was less evaluation of the effectiveness of clinical interventions.

Perhaps that is why, at the time, the NHS was easily the most cost-effective healthcare system in the world. But you couldn't ever really prove it because the data were, to say the least, somewhat lacking.

Any young person who reads this now must wonder how the NHS could have worked at all. But it did. And, given the level of funding at the time, it unquestionably achieved a big bang for its buck.

How could this be? In those days junior doctors worked all hours that God gave. Why? Ward sisters ruled their wards with rods of iron. Why? Clinics were conducted in a mad frenzy of work. Why?

Managers from Big Business might think that people with no rewards producing a product that was unmeasured would have no motivation. But there was a lot motivating those who worked in the NHS at the time. Junior doctors were more motivated then than now. Jobs, contrary to what today's juniors might think, were more scarce then than now. Your future depended very much on your latest clinical performance which was closely monitored by tiers of more senior juniors and a very small number of consultants, often just one. If your performance was below par it would be known about.

But people don't just work for money. People in healthcare see the 'product' before their eyes. They see the distress of disease or the distress of a patient lying in a pile of shit. Doctors have always wanted to make people better as soon as possible. Nurses have always wanted their patients to be comfortable. In those days matrons or sisters would be appalled if they ever found a patient left lying in a pile of poo by the then plentiful student nurses. If they saw that happening they would feign a swoon in front of the laggardly learner, pick themselves up and then clean up the patient immediately themselves to demonstrate the seriousness of the matter. That's why Dr Grumble stops ward rounds to do rectal examinations himself. It is to demonstrate the unacceptability of sloppy practice.

The NHS of old seemed a bit like the army at times. Quite possibly we could have continued this way just as the army continues this way. All our NHS really needed was the funding it is now getting. But instead we have gone along the lines of private business and, with that, vast amounts of money are being squandered on commissioning and billing and measuring and bonuses and, bizarrely, even advertising and PR.

Why, for God's sake, are we advertising? Why are we whipping up demand for ever more healthcare? Why are we creating unnecessary demand when we should be meeting necessary needs? Why do we have one part of the system purchasing services from another part of the system? It is like Sainsbury's buying produce from farms that it owns. Of course we all know that the supermarkets give the farmers a tough time. They are always screwing a better deal out of them. Better produce at cheaper prices. That makes sense. But driving through these deals takes time and effort. If you buy your produce direct it might actually be cheaper. There is more than one way of doing things. Really.

In many private hospitals if you have an aspirin they will charge you for it. Keeping tabs on it all is costly but that is the system. In the NHS they do not (yet) bother about the little things and the bills are called coding. It is an enormous effort to get it right and we often don't. Dr Grumble's hospital has some missing millions which may be because we haven't 'billed' for everything.

Why are we doing this? It is because somebody somewhere thinks that it would be better if we operated healthcare like Sainsbury's. We set up enormous expensive bodies to commission healthcare and we get them to bludgeon hospitals to give them good deals just like Sainsbury's bludgeons the farmers. The patients, like shoppers, will go to the place they think is best and inefficient hospitals will go to the wall. It's simple and obvious. Dr Grumble has almost convinced himself of the benefits.

But there are very many flaws to this model. The cost of running such a system is enormous and nobody has sufficient knowledge to do the commissioning to a high enough standard. Purchasing healthcare is not quite as simple as buying apples from a farmer. And for all the government's rhetoric about plurality, contestability and choice, the reality is that you are only likely to have your hernia fixed once. Shopping around is not really what most of us do when it comes to a stay in hospital. And generally the hospital down the road will be the one you are taken to in an emergency and the one you will want to go to if you need elective surgery.

None of this has ever really been thought through. Our government, to its cost, worships markets. Even the baled-out bankers are regrouping and once again are spinning the roulette wheels of the flawed money markets. And in the NHS, private providers, despite their very poor track record, are still the order of the day. The NHS as we know it is doomed.

With an election looming it is well to remember that getting Sainsbury's to tell us how to manage the health service was, originally, a Conservative Party idea. Just what can we expect from the next government?

﻿Sometimes David Cameron looks rather like lipstick on a pig.

Posted by
Dr Grumble

30 comments:

P Mitrale
said...

The only useful response to factually incorrect idiocy like that spouted by Hannen has to be to pick it apart, point by point. Unfortunately few people (certainly not me) have the willpower to stick with such a thankless task for long. Hence the self-interested free-marketeers who are driving this whole pseudo-debate from the shadows have a free run.

I don't think it is wise to call Daniel Hannan an idiot. Clearly, he isn't. Also, I am tired of reading MSM pieces shrieking about what he is supposed to have said but didn't.

Looking at Mt Hannan's blog and some of his complete interviews on You Tube shows a man who at least approaches issues from first principles and with an underlying philosophy. We need more of that, not less; we are where we are because of years of tinkering, fiddling and mish-mash.

From what I can see, the Singaporean approach to healthcare has some merit and perhaps some lessons.

and instead look at belgium, new zealand, italy, all much better health systems than either the UK or USA

whether you like it or not, real individual choice with each individual patient is the only proven way to dynamically drive up standards, the more real choice in patients hands the better

if you think there is anyway a top down centralist monopoly provider model can work youre mad, they cannot even sort out simple stuff like blood test appointments where patients end up wasting a whole day off work costing the country lots of wasted mantime

i look forward to the stalanist nutters who support the nhs being shut up and replaced by people who actually respond to what the patients think

oh and i think we need more folk in politics prepared to speak their mind rather than follow a bland lowest common denominator party line

When patients arrive at our A&E department staff must now say "Thank you for choosing the Trust".Obviously we are permitted some disgression during cardiac arrest.

We have also installed a supa-computer which provides up-to-date-information on waiting times in neighbouring departments - so if a patient has a nasty cold or bad back they can be seen even quicker, although they are still expected to arrange their own ambulance (most simply use the call box just outside the waiting room).

Admittedly those who are demented, psychotic or severely debilitated are slightly less able to take advantage of these exciting new arrangements.

20 or so years ago I was seconded to the DofH to identify the information needed for what was going to be the next Strategic Planning round. I was also asked to support 2 aspects of what was termed "Organisational Development" : relationships between clinicians and management and whether all staff could sign up to the same "key values". Unfortunteley at the same time the Government had lost patience with the medical profession. You might recall that the PM was being asked to defend actions taken in A&E departments about specific patients. I think the BMA etc had hoped to embarass the politicians - it backfired ... in a big way!

Years before on coming into Government, Thatcher's ministers asked the DofH how the NHS could be managed at less cost. After a brief survey of alternative models the politicians were told - it couldnot be done for a lot less and many other ways of providing health care were vastly more expensive in administrative costs. Your comparitive figures (3% vs nealry 30% bear this out)

The policitians did not like what they were told so bit the bullet... Well only until the attempts to embarass them broke an unspoken compromise between doctors and politicians. This compromise was along the lines of "Provide us with adequate resources and we will not go public on too many of the shortcomings of the service". The gloves came off and we have moved ever since into the dogmatic position the right wanted all along.

Nu Labour needed to appeal to the same "contented majority" if it was ever to gain power so despite initial attempts to undo some of these changes we have continued along the same path based on dogma and blind belief in the creed of choice and markets. Of course we have neither informed choice nor a well managed market in health care (- in my view cock up rather than conspiracy this time around. The Dof H has demonstated that it does not possess the intellect required to successfully implement any conspiracy as it would cock that up as well).

As a result the costs of "doing business" have rocketed - just as the politicians were told by civil servants over 20 years ago.

I agree that had the previous regime of health care administration been provided with the level of resources now there would have been far more bang for the buck, more meaningful involvement of patients and carers, a better quality of service and far less demoralised staff afraid to speak out and tell the taxpayers how poor a service they are getting for their money. In short we would have a more effective service rather than the apparant more efficient but wasteful one we have now.

If your last paragraph is right, Prisoner of Hope, (and I think it is) it is a tragedy that proper funding of the NHS did not happen before the introduction of the wasteful ersatz market. Unfortunately I cannot see any politicians engaging reverse gear. It seems from your fascinating account that they were told alternative systems would be much more expensive but took no notice. I can't see them taking any notice now. Especially with Big Business constantly trying to manipulate the outcome with carefully timed party donations and donations to influential charities.

We had a meeting a couple of weeks ago with 4 managers and 4 partners for PBCommisioning, lasted 2 hours and they asked us to review the cases of longstanding patients in hospital to see if they could be discharged!

I don't know who it was thought that the fundholding method of the 'money following the patient' was going to be a cheaper option than the old method of trusting the health board to get on with things. The result? A paper trail for every patient, money split into smaller, less effective pots and a huge increase in admin costs.

Just over 20 years ago - by the end of an International Health Executives Course at Cornell University - I had learnt a lot about the US health care system including the role of the federal HFA (Hospital Finance Adinistration) which had been introduced to control the costs of treatment provided to the elderly (under Medicare) and the poor (inder Medicaid). I also heard a lot about how former US Military were cared for by the Veterans Hospital Service.

The real losers were those who were not covered in this way and who could not afford the cost of health insurance. The numbers trapped in this way were reckoned to be around 50 million. It was a shocking revelation to a European. Also shocking was the realisation that uninsured medical costs were then the largest single cause of personal bankrupcy in the country.

Furthermore industrialists like Lee Iacoca were astonished to find that health insurance was the single largest component cost of every motor car produced. Families faced with selling possessions to afford the cost of hospital care for an ageing member, asked hospitals to place Do Not Resucitate (DNR) signs above their relative's bed.

Perhaps it is little wonder then that I expressed the hope at the end of course dinner that one day perhaps the initials H.F.A. in the U.S. might stand for Health For All. One person responded straight away with the remark "Don't bother - it will always stand for 'big bucks!' - that's all that matters in our health care system."

How sad then that just as President Obama tries once again to extend, what President Johnson started with Medicare, we in the UK seem hell bent on trying to recreate a US health care model of a quarter of a century ago appealing to envy, fear and greed instead of the altruism, benevolence and charity that underpinned our own socialised medicine for so long.

Prisoner of Hope, nobody is suggesting that the flawed US insurance system would ever be adopted in the UK. A sosial insurance system similar to that operated operated in France, Germany and Singapore would be the sensible option.

David @2/9/9 23:06 - Yes I agree that other models of funding and provision should be examined. As it happens I have also argued (for many years - even decades!) that the French approach offers many advantages.

Unfortunately UK health policy makers have tended to only look West - towards the US - and then in an uncritical manner.

As cockroach catcher indicates we are likely to face another wave of vested interests seeking refuge from commercial storms IF the U.S. health care system is reformed along Obama's plans for it.

20 years ago I used to ask health service staff if they believed in free markets, socialised medicine or somewhere in between which was characterised as "Well Meaning But Confused". The vast majority opted for this 3rd option. I think the proportions that now work in the NHS and who believe in free market mechanisms will have increased while the proportion who would support the socialised medicine model will have reduced.

However like the population (and electorate) as a whole the vast majority of NHS staff will probably still own up to being "Well Meaning But Confused".

Sadly I suspect all commentators on this topic will agree that we are unlikely - as a result of the next General Election campaign - to clarify the issues in such a way that will reduce the ranks of the well meaning and confused.

“In 2004 Simon Stevens left Downing Street to head the European division of UnitedHealth. In January he went to America as chief executive of Ovations, the division of UnitedHealth which provides insurance packages for older patients. It is an intensely competitive market in the US, with Ovations accounting for $25bn of the companies' $72bn revenue last year. It also includes Medicare, the state-funded programme which provides healthcare for the over-sixties.“The company is a huge force within US healthcare, with 70 million Americans on its books, employing 400,000 doctors in 4,000 hospitals. UnitedHealth is America's biggest health insurer. And it's growing in influence in Britain.“It already runs two GP practices in Derbyshire and now the government has given the green light to 14 companies, including United, to bid for potentially much bigger contracts from the primary care trusts that run hospitals. They would be paid for providing data analysis and research, giving trusts a clearer idea of how to manage patients with chronic conditions such as diabetes.”

This is not 1948. The country is very different as are the people in it. Even the medical training of 20 years ago is vastly different in content from today and the general populace s less homogeneous.

The NHS is basically an International Health Service available to anyone who walks in the door after a short flight from anywhere in the world. It is simply alien to the concept of the 1950s.

It is impossible to keep funding a system where rationing is imposed so others can gorge on treatments determined by political fiat and available to anyone regardless of citizenship or contributions.

The NHS was appropriate to a country with border controls and full-employment; it cannot survive in a world of mass benefit-unemployment, mass immigration, demographic change, and consumer-driven demand for medications.

That said it is not clear that other systems have the answer, simply that the NHS as was is unsustainable

Tom Tom said ........ "It is impossible to keep funding a system where rationing is imposed so others can gorge on treatments determined by political fiat and available to anyone regardless of citizenship or contributions".And ........."The NHS was appropriate to a country with border controls and full-employment; it cannot survive in a world of mass benefit-unemployment, mass immigration, demographic change, and consumer-driven demand for medications".

Well put Tom Tom - I cannot recall the problem being described quite so succinctly.Our world today is certainly very different from 1948 - for starters there was more than twice as many hospital beds back then.http://www.guardian.co.uk/society/2008/jun/22/nhs60.nhs1

In the present climate it is virtually impossible to discuss about these issues without being labelled a racist, ageist, or sexist, etc, etc.

We seem to have got ourselves into a mess partly because we are unsure of what we an and can't say?

The NHS can be funded by the EMPLOYED through the usual NI contribution and the UNEMPLOYED through the Lottery!!! The state should take over the Lottery with no such thing as bonus for its CEOs and the lottery used purely for NHS. The unemployed played the lottery at 3 to 5 times that of the employed.

"The NHS was appropriate to a country with border controls and full-employment; it cannot survive in a world of mass benefit-unemployment, mass immigration, demographic change, and consumer-driven demand for medications."

Hear, hear. Hence the only way forward is, as Darwin puts it, to adapt. This can happen by not only understanding and supporting change, but by encouraging and allowing same to happen and for this, you need a change of mind set as well as change of culture.

since the country has tens and tens of thousands of indian nationals here on "inter company transfer" visas employed by the outsourcers cognizant, tata, tech mahindra, wipro etc

and each of these can bring in a family, and each of them is entitled to free nhs and state education from day one

and after a few years here they get indefinite leave to remain

and this bypasses totally the work visa system

undercuts the wages a european can work for

the workers are treated very badly

the employment and visa laws are broken routinely

we do not have managed migration we have floods of indian workers and their familys

BT has stopped hiring grads, they hire them in india instead into their tech mahindra subsiduary and bring them into the country on inter company trasnfer visas

We are using these years to train up a nation which will be our biggest competitor

and we have no shortage of European nationals with the skills, many forced out of work by these practises

If we continue to allow the use of such Visas and totally unrestrained immigration then yes the NHS is dead, and the BNP really will build on their current success

When I work abroad I PAY FOR MY HEALTH CARE AND THE EDUCATION OF MY KIDS, why do we give free health care to Indian nationals and their large families here on inter company transfer visas? many very ill people come into the country this way

The amazing thing is that despite the BMA's support of public ownership of the NHS, many of its members (including some of its leaders) are cashing in on the opportunities provided by the private sector and are undermining their campaign!

The NHS can survive immigration and demographic change. As long as those who work pay national insurance there shouldn't be a problem. People might be different colours and races but the colour of money is always the same.